The Patient Protection and Affordable Care Act (ACA, also known as ObamaCare) became law on May 23, 2010. It strives to reform the health insurance and health care industries in an effort to cut health care costs and provide Americans with affordable health insurance. The ACA also strives to expand Medicare and Medicaid to assist those Americans who cannot currently afford health insurance. As a result of the reforms, there may be a significant influx of patients into the health care system. In addition, there will be a greater focus on integrating health care services, particularly for individuals with physical and mental health conditions. It is expected that under the ACA, social workers will take a more active role in the coordination of care for existing and new members of the health care system. Social workers will also provide additional direct, frontline services to patients.To prepare for this Discussion, review this week’s resources. Consider the debate over the ACA and explore the reputable sources on the Internet for additional resources on the balanced debates over the ACA. Consider how the ACA might expand meaningful services to all Americans including children, young adults, uninsured minorities, and spouses of employed individuals. Consider one population.By Day 4Post a description of the findings of your research on the debate over ACA. Explain some of the misconceptions or misunderstandings the general population might have about the ACA. Explain how the ACA may or may not increase affordability, health insurance coverage, and access to health care services for the population you selected. Explain the potential or documented influence of the ACA on medical social work practice. Describe the medical social worker’s role in clarifying the ACA to patients and families.
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AMERICANS’ ATTITUDES TOWARD
THE AFFORDABLE CARE ACT:
WOULD BETTER PUBLIC
UNDERSTANDING INCREASE OR
TOBIAS H. STARK2
This research was conducted with support from the Robert Wood Johnson Foundation, GfK,
Stanford University, and the Associated Press. The authors thank Arthur Lupia and Michael Tomz
for helpful comments on this manuscript.
Stanford University and Utrecht University. email@example.com
3 Stanford University. firstname.lastname@example.org
4 University of Michigan. email@example.com
5 Princeton University, firstname.lastname@example.org
6 Associated Press‐NORC Center for Public Affairs Research. tompson‐
7 Associated Press. email@example.com
8 Associated Press. firstname.lastname@example.org
National surveys conducted in 2010 and 2012 suggest the following conclusions:
American understanding of what is and is not in the ACA has been far from perfect.
Correct understanding of the elements of the bill we examined varied with party
identification: Democrats understood the most, independents less, and Republicans still
Older people and more educated people have understood the elements of the bill we
examined better than have younger and less educated people.
Between 2010 and 2012, public understanding of the elements of the bill we examined
did not change notably.
Most people have favored most of the elements of the ACA that we examined, but not
everyone recognized that these elements were all in the plan.
Most people opposed policies that were sometimes falsely thought to be parts of the
If the public had perfect understanding of the elements that we examined, the
proportion of Americans who favor the bill might increase from the current level of 32%
Taken together, all this suggests that if education efforts were to correct public misunderstanding
of the bill, public favorability might increase considerably.
The Patient Protection and Affordable Care Act of 2010 (ACA) enacted a series of significant
changes to the American health care system. The 900‐page‐long bill, which elicited an extremely
partisan reaction and substantial news media interest, amended the U.S. code to prevent insurance
companies from denying coverage for pre‐existing conditions, provide for health care exchanges
where individuals could purchase care directly, require all individuals to have health insurance or
pay a fine, and more. In June, 2012, the U.S. Supreme Court upheld a central element of this law.
Public debate about the bill called attention to many aspects of the law that were included
in the version that Congress approved. But during the course of public debate, a number of
inaccurate claims were made, asserting that the bill included provisions that were not included in
the final version. Some of the widely discussed components were part of the legislation, such as the
plan to allow children to stay on their parents’ health plan through age 26. But other widely
discussed notions were never considered for inclusion, such as the claim that a panel of bureaucrats
could decide when coverage would be given (the so‐called “death panels”). The legislation included
a variety of less‐often discussed provisions, such as charging a fee to insurance companies that
offered particular types of insurance.
Many surveys were conducted both before the bill’s passage and after its enactment to
gauge the American public’s reaction to it. In early 2010, public opinion was fairly evenly split. For
example, according to a Kaiser Family Foundation (KFF) survey in April of that year, 46% of
Americans said they had a favorable opinion of the bill, and 40% said they had an unfavorable
opinion. A year later, in April 2011, KFF reported these two statistics to be 41% and 41%,
respectively. And in January 2012, the figures were 37% and 44%, respectively, perhaps suggesting
a slight shift in the unfavorable direction as time has passed. In May 2012, the figures were
identical: 37% and 44%, solidifying evidence of that slight shift. And in August 2012, these figures
were 38% and 43%, respectively.
A similar portrait was painted by AP‐GfK polls. In May, 2010, 39% of respondents said they
supported the ACA, and 46% said they opposed it. In June, 2012, those numbers were 33% and
47%, respectively. Thus, a small decrease in the proportion supporting, and a small increase in the
Surveys done by other organizations provided similar, though not identical, portraits of the
balance and trajectory of opinions. For example, a NBC News/Wall Street Journal poll done in May,
2010, found 38% of respondents saying they thought the ACA was a good idea, and 44% said it was
a bad idea. As of June, 2012, that organization found these figures to be 35% and 41%. Thus, the
proportion expressing a positive opinion dropped slightly, like the KFF polls. But the proportion
expressing a negative opinion also dropped slightly.
Only one prominent national survey research organization, The Pew Research Center,
reported results suggesting movement in the opposite direction. In January, 2011, 41% of their
respondents approved of the ACA, and 48% opposed. Their most recent survey, in June‐July, 2012,
found that 47% approved, and 43% opposed.
Put together, most national surveys during the last two years support two principal
conclusions: (1) public opinion has not manifested a sizable and consistent leaning toward being
favorable or unfavorable toward the ACA, and (2) a slight shift in the negative direction may have
occurred since the law was passed.
It would be understandable to look at such evidence as an indication that the American
public does not strongly support this piece of legislation. After all, if about as many people favor it
as oppose it, and if we have never seen a majority favoring it, that hardly sends a strong signal of
support. Furthermore, it is easy to imagine that since passage of the bill, Americans have had time
to consider the bill and its implications in more and more depth, and if such consideration leads to a
shift in the negative direction, that certainly signals quite the opposite of enthusiasm. Thus, such
data could be taken as a signal that Republican efforts to repeal the bill would be warmly welcomed
by a growing group of Americans.
At the same time, the very same polling evidence can be viewed from the opposite
viewpoint. Although a majority of Americans have not favored the bill, it is also true that a majority
have never opposed it, either. And even after the recent small increase in opposition, the
proportion opposing it does not exceed 50%. So direct questions asking about positive vs. negative
evaluations of the plan have not documented a mandate from the public to repeal the bill.9 Taken
together, all this evidence portrays the American public in what might seem a typical way: split
about evenly, and not providing a clear mandate to elected representatives one way or another.
It would therefore not be unreasonable for those representatives to look at this polling
evidence, reach that conclusion, and proceed to take actions in keeping with the guardianship view
of democracy: deciding what they feel is best for the country and taking action (or doing nothing)
accordingly, regardless of public opinion.
Such ignoring of public opinion might also be justified from another perspective as well. In
so many survey‐based investigations of the American public for many decades, people have been
found to perform quite poorly on quizzes assessing factual knowledge about domains in which
significant legislation has been considered or passed. If most people lack the facts needed to truly
understand the problems to be solved by a piece of legislation and the solutions offered by that
legislation, why should public evaluations of the legislation be taken seriously? That is, the public
might feel very differently if they truly understood a bill, so opinions based on partial information
or substantial misconceptions can certainly not be described as “wise” and should perhaps
therefore be ignored by legislators.
Of course, ignoring public opinion, even uninformed public opinion, may place legislators at
risk come election‐time. Even when the public does not understand a piece of legislation, members
of the electorate may nonetheless hold strong opinions about it, either favorable or unfavorable,
and those opinions may shape their voting down the road. Indeed, a great deal of research suggests
that public opinion on policy issues does sometimes shape vote choices (see Anand & Krosnick,
2003; Krosnick, 1988). So a legislator who votes against a piece of legislation that voters favor may
asking whether the bill should be repealed have sometimes shown a majority of Americans
find himself or herself later paying an electoral price if that vote becomes well publicized by the
legislator’s opponent during a campaign, even if public understanding of the legislation is seriously
In a situation such as this, legislators who wish to see a piece of legislation passed (or avoid
its repeal) always have the option of informing the American public about what the legislation
would truly do, in the hope that better understanding would lead the public to offer a stronger
signal of support to their elected representatives. But would such education indeed lead to more
support? This presumably depends on the nature of the public’s misunderstandings and on the
public’s evaluations of the elements they believe compose the legislation and of the elements that in
fact compose it.
In this paper, we report an investigation of exactly these issues with regard to the ACA.
Using data from two surveys (one conducted in 2010 and the other in 2012), we explored:
1) How accurately Americans have understood what is in the ACA and what is not.
2) How the accuracy of people’s understanding has changed during the two years since the
bill was passed.
3) How knowledge accuracy is related to favoring the ACA – that is, whether people who
know more about what’s in the ACA like it more or like it less,
4) How the public would feel about the ACA if everyone understood that a series of its
central elements are indeed included in the ACA and that a series of frequently
discussed but ultimately omitted elements are not in it.
Along the way, we investigated two other issues:
1) The predictors of accurate understanding of the plan ‐ that is, which types of people are
more and less likely to score well on a quiz.
2) The popularity of various specific elements that were included in the plan, and how
popular are elements that were not included but were sometimes claimed to be.
In carrying out this investigation, we implemented a new approach to measuring public
understanding of a public policy issue. In surveys done during the last 80 years, it has been routine
to test knowledge by asking people factual questions and grading people as either correct or
incorrect based upon whether their answer matched the facts or not. But this approach ignores a
simple and unavoidable fact: that a respondent saying to a survey interviewer that members of the
Republican Party outnumber members of the Democratic Party in the U.S. House of Representatives
does not necessarily mean that the respondent believes this to be true. When asked which party
holds more seats, a respondent might simply guess and end up giving the correct answer by chance
alone. This response would not reveal a belief that the respondent genuinely holds, nor would that
purported belief have any impact on his or her thinking, because he or she does not truly hold that
perception of the world. Guessing seems likely to especially distort answers to quiz questions that
offer only two response choices, as we used here (is this included in the ACA or not included in the
One might imagine that this problem can be overcome by explicitly offering survey
respondents the opportunity to decline to answer a survey question by saying they “don’t know”
the answer and encouraging them to do so. But a great deal of research suggests that this strategy
is unwise. Instead of attracting only and all of the people who truly do not hold a belief on an issue.
“don’t know” response options attract many respondents who truly hold opinions and fail to attract
respondents who hold opinions with little or no certainty (for a review, see Krosnick, 2002).
The solution to this problem is suggested instead by a literature in psychology on certainty.
The intended purpose of offering a “don’t know” option is typically expressed as filtering out people
who would express a judgment with no certainty at all. That is, a person might say “I think that the
Democrats hold more seats, but I’m not at all confident about that guess.” Thus, the preferable
solution is to first ask people to make their best guess and then to ask them to rate the certainty
with which they express that belief. This allows researchers to filter out people who offer opinions
with little or no certainty.
A collateral benefit of this approach is that certainty strongly correlates with use of beliefs
during decision‐making. People who hold a belief with confidence are inclined to use it when
making highly relevant decisions. In contrast, people who hold a belief with minimal confidence are
unlikely to use it (for a review, see Petty & Krosnick, 1995). Thus, giving survey respondents
“credit” for accurately possessing a belief only when they express high certainty allows us to
identify those beliefs that are also likely to have shaped people’s overall evaluations of the ACA.
Therefore, in keeping with this perspective, when we administered quiz questions assessing
public understanding of the ACA, each question was followed by a question asking respondents
how sure they were about their answer to the prior question. People who expressed high degrees
of confidence when giving a correct answer were treated as holding an accurate belief, and people
who gave a correct answer while expressed low degrees of confidence were not credited as having
an accurate belief, nor were people who answered the quiz questions incorrectly.
The elements of the ACA that were addressed by the quiz questions were selected carefully
to cover most of the central elements of the plan. In their document entitled “Focus on Health
Reform: Summary of New Health Reform Law” (Publication #8061; www.kff.org), the Kaiser Family
Foundation provided what they called a “summary of the law and changes made to the law by
subsequent legislation.” We relied on this summary to select the elements of the ACA to ask about
in our survey. We also asked about an additional set of policies that were not ultimately included in
the ACA but were discussed during the public debate of it.
Data and Methods
The data for this study come from two cross‐sectional surveys of nationally representative samples
of American adults conducted via the Internet by GfK (formerly Knowledge Networks).
Respondents were drawn from the KnowledgePanel® ‐ a nationally representative panel recruited
via random digit dialing and by address‐based sampling. The sampling design covers 97% of the
American population, including households that do not have Internet access or a land line
telephone. All panelists were remunerated for their participation; people who did not already have
either a computer or Internet access were provided them. Upon joining the panel, panelists first
completed a core profile questionnaire that captured information about their race, gender, age,
income, education, and more. For each subsequent survey, panel members were selected using a
probability proportional to size (PPS) weighted sampling design, producing a sample that is
representative of the American population.
The first survey for this project was conducted between August 31 and September 7, 2010.
A random sample of 1,815 adults was invited to participate, and 1,271 completed the survey
(completion rate = 70%). The median time spent completing the questionnaire was 26 minutes.
The second survey was conducted between August 3 and 13, 2012. GfK invited 2,344
American adults to participate, and 1,334 completed the questionnaire, a completion rate of 57%.
The median time spent completing the questionnaire (which was much shorter than the
questionnaire used in 2010) was 17 minutes.
All analyses reported below were conducted using weights to adjust for unequal probability
of selection and post‐stratifying based on demographics.
Table 1 displays various percentages needed for the calculation of response rates for the
survey and displays various the breakdown for the response rates for both surveys.
A. Panel Recruitment
B. Household Profile
C. Household Retention
D. Survey Completion
E. Active Rate
Table 1: Response Rates
Appendix B displays the demographic profiles of both samples.
Knowledge and Certainty
Respondents were asked 18 knowledge quiz questions, probing whether specific provisions were in
the health care bill. Respondents read one description at a time and indicated whether they
thought the provision was “in the bill” or “not in the bill” that Congress passed in 2010.
Twelve of the elements were principal provisions of the ACA. The remaining six elements
were not in the bill but had been frequently discussed in public debate; these elements were
identified by experts at the Associated Press and researchers at Stanford University. Appendix A
shows the instructions for respondents, the full list of questions, and the correct answer for each
Following each quiz question, respondents were asked, “How sure are you about this?” The
answers “extremely sure” and “very sure” were coded 1 (certain), and the answers “moderately
sure”, “slightly sure”, and “not sure at all” were coded 0 (uncertain).
To measure each respondent’s level of knowledge, we first computed the percent of the 12
provisions of the ACA that the respondents correctly identified as such with high confidence. Next,
we computed the percent of the 6 provisions not in the ACA that the respondent correctly identified
as such with high confidence. Then, we averages these two percentages to yield a final knowledge
score for each respondent. Consequently, the fact that twice as many questions tapped knowledge
about provisions in the bill as tapped provisions not in the bill did not cause the final index score to
be based more on understanding of the elements in the bill than on understanding of the elements
not in the bill. The final knowledge score ranged from 0% for people who did not identify any
provision correctly with high confidence, to 100% for people who properly identified all provisions
with high confidence.
Evaluation of the ACA
In the 2012 survey, respondents were asked, “In general do you favor, oppose, or neither favor nor
oppose the law changing the health care system that the U.S. Congress passed in March 2010?” The
responses “favor strongly” and “favor somewhat” were coded 1 (indicating favoring), and the
responses “neither favor nor oppose”, “oppose somewhat”, and “oppose strongly” were coded as 0
Support for ACA Plan Elements
Respondents were also asked to indicate whether they favored or opposed each of the 18
provisions addressed by the quiz questions. On each screen, respondents were asked “Do you favor
oppose this change?” along with a statement des …
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